1. Clear the Clutter: Sage Advice on De-Prescribing Kimberly Wintemute MD CCFP FCFP National Primary Care Co-Lead Annual Clinic Day in Family Medicine, London ON May 11, 2016

2. Low-value, high-risk meds

5. Drugs of Interest ( more harm than good, safer alternatives exist) Sedative-Hypnotics PPIs Long-acting Sulfonylureas

6. De-Prescribing: Generic Approach Decide what to change / demonstrate the problem Build Consensus within Team – Risks – Indications for ongoing use in some patients Plan intervention with Team – How to identify patients – How to reach patients – Define intervention and tools

7. De-Prescribing: Generic Approach Start and Monitor Intervention Tweak Intervention as needed Measure & celebrate success after defined duration

9. CWC Recommendation Don’t maintain long-term PPI therapy for GI symptoms without an attempt to stop/reduce at least once per year for most patients Canadian Association of Gastroenterology

10. Rationale 30-60% of those on PPI lack appropriate indication Risks Community & hospital-acquired pneumonias C. Difficile Fractures Low Mg: arrhythmia, myalgias, tremors Low B12 Chronic kidney disease

11. Indications for long-term PPI use Chronic NSAID use Hx GI bleed Barrett’s esophagus Los Angeles Grade D (severe) esophagitis

12. Toronto Western FHT Results: 93% of patients had PPI reassessed 26% of patients stopped or decreased dose

13. North York FHT Jan-March 2016 1603 charts flagged “consider de-prescribe PPI” 88 visits 6 needed PPI for medical indication 38 / 82 agreed to d/c PPI

15. CWC Recommendation Don’t use benzodiazepines or other sedative- hypnotics in older adults as first choice for insomnia, agitation or delirium Canadian Geriatrics Society Canadian Society of Hospital Medicine Canadian Academy of Geriatric Psychiatry

16. Rationale Always more harm than good Risks Falls & their complications Hip fractures & their complications Delirium Motor vehicle crashes Hypoventilation Death Interference with cognition & cognitive therapy

17. Rationale Dependency takes 2 weeks to develop Benefit: 23 minutes more sleep NNT: 13 NNH: 6

18. Indications for sedative-hypnotic use Seizure disorder Alcohol withdrawal Refractory anxiety Restless leg syndrome

20. EMPOWER Trial Université de Montréal RCT: 30% in treatment arm stopped sed-hypnotic 5% in control arm stopped sed-hypnotic

21. Paper Charts Focus on one initiative, opportunistically and for a duration Example – Benzodiazepines in > 65 for 3 months – Glyburide > 65 for 3 months

22. Work on De-Prescribing Initiatives

23. Share De-Prescribing Initiatives

25. On-line De-Prescribing Resources http://deprescribing.org http://deprescribing.org/resources/deprescribing- algorithms/ http://deprescribing.org/resources/deprescribing- algorithms/ http://www.choosingwiselycanada.org/in- action/toolkits/ http://www.choosingwiselycanada.org/in- action/toolkits/